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By modifying the appropriate use criteria (AUC) for transthoracic echocardiograms (TTEs) and educating physicians on which tests should be performed in an inpatient versus outpatient setting, researchers at Bridgeport Hospital in Connecticut reduced their inpatient echo order volume by 11.1 percent and boosted the efficiency of their department.

The educational component of the intervention, which was directed at clinicians who most frequently ordered tests, included outlining three key areas: the “rarely appropriate” reasons for an inpatient TTE, the appropriate indications for STAT requests and portable order studies and the common indications for repeat TTEs.

“We thought our echo department could definitely function a lot more efficiently than it was at that time,” said John-Ross Clarke, MD, an internal medicine resident at Yale New Haven Health and Bridgeport Hospital, who presented his team’s work at the American College of Cardiology’s Cardiovascular Summit in Orlando. “We thought a lot of the reason for the inefficiencies were that a lot of the inpatient echos that were being ordered could be ordered as an outpatient.

“We also found that a lot of the physicians were overutilizing ‘STAT’ requests as well as portable studies and that was taking our sonographers away from being able to perform echos for other inpatient as well as outpatient studies,” Clarke told Cardiovascular Business.

STAT requests are supposed to be reserved for studies that require immediate attention, but some clinicians use that setting as a default in an effort to get their images processed faster. In fact, one 2017 study showed more brain MRIs were ordered as STAT than non-STAT at one Atlanta hospital, making the mean turnaround time for those studies even longer than routine brain MRIs.

Clarke et al. implemented a two-month period to cover their educational components, using the 2011 AUC for TTE as a starting point and then tweaking the recommendations based on the inpatient ordering patterns at their institution. Many indications for routine surveillance of conditions, including systemic hypertension, cardiomyopathy or prior pulmonary embolism, were deemed “rarely appropriate” in an inpatient setting when there wasn’t a change in clinical status or a change in management being considered.

The researchers also worked with their health system to simplify the nomenclature for ordering TTEs within their electronic medical record (EMR).

Following the educational period, the volume of inpatient echocardiograms dropped by 11.1 percent from baseline, duplicate echo orders dropped by 32.1 percent and the average time from ordering an echo to getting it read declined by 46.6 percent. These improvements were observed within four months.

Clarke and colleagues are still analyzing their data to determine the proportion of TTEs that fall within the three categories of the AUC: appropriate, may be appropriate and rarely appropriate.

“Our assumption is that most of our (remaining) volume were the appropriate studies but we haven’t actually done subgroup analyses yet to see what’s the actual breakdown of those studies that are no longer being ordered,” he said.

In addition to simplifying the language in the EMR ordering process, the researchers are implementing an EMR tool that will require users to log AUC diagnoses for inpatient studies. They believe these changes could further increase the efficiency of their echocardiography department.